Enterocutaneous fistula (ECF) is a challenging clinical problem with many etiologies; however, the most common cause is iatrogenic, complicating abdominal surgery. Advances in the overall care of the ECF patient have resulted in dramatic reductions in morbidity and mortality over the last five decades. A structured approach to the management of ECF has been shown to result in improved outcomes. Initial physiologic stabilization of the postoperative patient, focused on hemodynamic and fluid support as well as aggressive sepsis control are the critical initial maneuvers. Subsequent optimization of nutrition and wound care allows the patient to regain a positive nitrogen balance, and allow for healing. Judicious use of antimotility agents as well as advanced wound care techniques helps to maximize healing as well as quality of life, and prepare patients for subsequent definitive surgery.